Breastfeeding Medicine

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Support for Lactating Medical Trainees

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Authored by: Sarah Shubeck, MD and Megan Pesch, MD, MS

The culture of medical training and demands of residency work is often regarded as not conducive to the needs of lactating physicians. The need for “breaks” or perceived lack of dedication to workplace can lead to misperception of lactating trainees and pressures to stop milk expression before reaching an individual’s goal. Additionally, recent work has demonstrated that physician mothers struggle to meet their personal breastfeeding goals at rates higher than their peers, most often attributed to the demands of their work and lack of workplace support and infrastructure.

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Those successful lactating medical trainees have squeezed in quick “pump breaks” in between patients or cases, struggled with mastitis or discomfort from extending duration between milk expression, or have experienced being reprimanded for taking time to express milk. Additionally, the lack of clean and available lactation spaces result in women turning to bathroom stalls or skipping times for expression. Despite these discouraging and humiliating encounters, many lactating medical trainees have found success through pressing on individually, but often with having to sacrifice their supply and morale and compromise their personal breastfeeding goals.

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The plight of the breastfeeding medical trainee has received recent well deserved attention. Several publications, including those by Livingston-Rosanoff et al., and Pesch et al, have highlighted these difficulties and proposed protections and education around the needs of lactating physicians. This recent work highlights three key components:

  • First, there is a critical need for supporting trainees to be allowed time for milk expression as determined by the trainee and her healthcare providers. For example, residents are often hesitant to ask for a “pump break,” but departmental support for milk expression times allows women residents to meet their health needs without sacrificing learning opportunities.
  • Second, as required by federal mandate, medical resident employees must be provided lactation spaces that are clean, private, and close to patient care settings to minimize time away from clinical and educational opportunities. Program directors and departments can work to provide convenient and private spaces through creative use of call rooms and empty patient care settings to meet the needs of their lactating trainees.
  • Finally, creating an open and supportive culture around lactation within a department and institution is essential. Workplace education of faculty, staff, and trainees and the adoption of policies and guidelines can protect and support lactating trainees can function to normalize lactation in medical training. (See Livingston-Rosanoff et al., and Pesch et al, for examples of policies and guidelines).

Supporting lactation for medical trainees is not only the right thing to do for their health and wellness, but it will almost surely have a trickle-down effect to the care they provide their breastfeeding patients.

Written by bfmed

June 6, 2019 at 8:07 am

Eliminating Disparities in Breastfeeding and Infant Mortality: Conference 2018

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Eliminating Disparities

Although breastfeeding rates are increasing in the US, significant disparities in breastfeeding and infant mortality persist.  Cincinnati Children’s Hospital Medical Center and partners were delighted to host the “Third Annual Conference to Eliminate Disparities in Breastfeeding and Infant Mortality:  Taking Action for Equity” as a pre-Conference to the Ohio Infant Mortality Summit at the Duke Energy Convention Center in Cincinnati, Ohio.  Our Keynote speaker was the inspiring Dr. Camara Jones from Morehouse School of Medicine, who helped us critically examine how racism must be acknowledged and addressed to make inroads toward health equity.

Our First Annual Conference with Keynote speaker, Dr. Michal Young, helped us to define the problem of breastfeeding disparities and infant mortality.  The Second Annual Conference featured Keynote speaker, Dr. Kimarie Bugg, who took us deeper by addressing the role of Implicit Bias.  Our participants provided feedback, requesting to leave the next conference with Action Tools to make changes in their own communities to eliminate disparities so this year we are “Taking Action for Equity”.

To that end, our Conference this year began with an inspiring opening from City of Cincinnati Health Commissioner, Melba Moore, who challenged everyone to develop novel ways to improve community health.  From there, the conference highlighted the successful efforts of 42 speakers from around the State of Ohio and beyond, representing these programs:  CenteringPregnancy, the State of Ohio efforts to improve breastfeeding (Ohio First Steps, WIC, Ohio Department of Health), Hospital Quality Improvement, the importance of Fathers, and the amazing work of Doulas.  These programs provided the first set of Key Highlights to nearly 400 health care providers, community members, and parents, who then were able to “go deeper” in workshop formats, along with an option to learn the basics of “Breastfeeding 101.”  After lunch, attendees rejoined for a second set of Key Highlights, with representatives from Home Visitation programs, Mom-to-Mom Support groups (https://www.facebook.com/Avondale-Moms-Empowered-to-Nurse-1257926900973280/), Rural and Appalachian breastfeeding groups and Breastfeeding while Going back to Work.  These presenters also provided a deeper dive with workshop sessions, and the option for a “Breastfeeding 911” course to help front-line providers and support people troubleshoot common problems.  Each workshop provided a take home “toolkit” for attendees.

In addition to many local Cincinnati area efforts to eliminate disparities in breastfeeding, we were delighted to have experts from Cleveland, Columbus and beyond share their expertise with us.  The Doula segment was especially exciting  as co-presenter, Jessica Roach from ROOTT (Restoring Our Own Through Transformation) arrived to the conference JUST as her bio was being read, (coming, of course, from a delivery, directly to the stage!), as well as Christin Farmer, at Birthing Beautiful Communities in Cleveland who brought her “Dude-la”, Neal Hodges!  We learned about ROBE (Reaching Our Brothers Everywhere) from our local Wisdom Council Member, Calvin Williams, and Founder, Wesley Bugg, Esq., the CenteringPregnancy program in Cleveland , and so many more Ohio highlights!

Dr. Lori Winter and Dr. Julia Ware

Dr. Lori Winter and Dr. Julia Ware

Conference Commissioner Moore, Camille Graham, Corinn Taylor, Karen Bankston

Commissioner, Melba Moore, Dr. Camille Graham, Dr. Corinn Taylor, Dr. Karen Bankston

Dr. Camara Jones and Jamaica Gilliam

Dr. Camara Jones and Jamaica Gilliam

Dr. Camara Jones took us through an intensive discussion of the multiple dimensions through which racism drives health disparities using her powerful 3-dimensional cliff analogy highlighting differences in: the quality of care received within the healthcare system, access to healthcare and preventive services, and life opportunities, exposures, and stresses that result in differences in underlying health conditions.

She defines racism as “a system of structuring opportunity and assigning value based upon the social interpretation of how one looks. Racism is a system that:

  1. Unfairly disadvantages some individuals and communities
  2. Unfairly advantages other individuals and communities
  3. Saps the strength of the whole society through the waste of human resources.

Racism has created inequities in our country. Dr. Jones helped us to see that the barriers to health equity include the narrow focus on the individual (“I am not racist, so these facts don’t apply to me or how I treat my patients!”); the fact that we are an “A-historical” culture that is disconnected from and fails to acknowledge our recent past (“Slavery ended more than a hundred and fifty years ago – why can’t you get over it?”; we don’t recognize the underlying structural system of inequity and privilege that is at the foundation of health disparities (“Why is it that a mom’s zip code is more likely to predict birth outcomes, infant survival, and breastfeeding success than her access to health care?”); and that we are instead overly focused on the myth of meritocracy – an example – two babies – equal opportunity or equal potential? (“They just aren’t trying hard enough – they could breast feed if they really wanted to!”)

Some key takeaways from Dr. Jones:

  1. When you feel uncomfortable, “LEAN IN”
  2. To achieve health equity we need to:
    1. Value all individuals and population equally
    2. Recognize and rectify historical injustices
    3. Provide resources according to need
  3. You can learn more about Dr. Jones’ Cliff Analogy in this 5 minute video by the Urban Institute.

An added treat to the Conference was an optional learning lunch with new AAP Section on Breastfeeding Chair, Dr. Lori Feldman-Winter, who was giving a talk on Safe Sleep and Breastfeeding at a Safe Sleep Summit occurring simultaneously to our Conference!  Over 130 of our participants were able to join this event, and enjoyed the review of the evidence and guidelines for safe sleep and breastfeeding from the AAP lens.

One of the most exciting aspects of the Conference is still to come.  We will harness the energy generated from the diverse Conference presenters and attendees to continue improving breastfeeding rates in marginalized populations. It is clear that we have a wealth of talent and will need to use many different strategies to achieve this goal. Our participants are filling out a “Call to Action” survey as part of their Conference evaluation, so that we can continue to connect and collaborate in areas of interest to eliminate disparities through learning communities across the state. Stay tuned for More to Come!

Pre- and post-conference video clips:

http://www.fox19.com/video/2018/12/14/breastfeeding-disparities-challenges/

http://www.fox19.com/video/2018/12/14/breaking-down-barriers-breastfeeding/

Shared Safe Sleep and Breastfeeding Posters (unbranded) from Ohio First Steps:

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Feeding-Safe-Sleep-flierUNBR.pdf

www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Breastfeeding/First-Steps-2017-Spanish-Feeding-Safe-Sleep-flier.pdf

Cincinnati Children’s Conference Co-Chairs:

Julie Ware, MD, MPH, FABM and ABM Board Member

Laura Ward, MD, ABM Member

Camille Graham, MD, Executive Community Leader

 

For more information, please contact Dr. Julie Ware, julie.ware@cchmc.org

Blog posts reflect the opinions of individual authors, not ABM as a whole.

Written by julieware2

April 16, 2019 at 11:42 am

Where will you be when (not if) you fall asleep while feeding your baby?

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Healthy newborns wake easily and often to feed, and a “good sleeper” in this age group is one that lets you know when he or she is hungry, is an efficient and effective feeder, and settles after the feeding and falls back asleep.  Modern societal expectations often do not allow for or encourage new mothers to sleep during the 16-20 hours/day that a newborn sleeps.  There is often housework, family and visitors, thank you notes, older siblings, and far too often at least in the U.S., an earlier-than-it-should-be return to work.  The “village” that traditionally swooped in and surrounded the dyad with care and support is often spread across miles, even oceans, and these mothers, while still recovering from birth, are left alone as their partner returns to work.  It is not surprising that new mothers find themselves exhausted and in “survival mode” during which time the recommendations that they have heard to feed a certain way or have the baby sleep a certain way may fly out the window as they desperately try to achieve a little more sleep.  And even though they may or may not be planning to, mothers of newborns are falling asleep while feeding their babies.

In addition, depending on where they turn for information, the recommendations for infant feeding and safe sleep can be confusing and may appear to be at odds with one another.  We know that mothers who bedshare with their infant breastfeed for longer.  We also know that where babies start off the night is not always where they end up in the morning.  We know that breastfeeding is protective against Sudden Infant Death Syndrome (SIDS), but also that bedsharing may pose a risk for a sleep-related infant death, particularly in the setting of other risk factors such as prenatal smoking, formula feeding, maternal substance use, sedating medications, maternal obesity, prematurity, and the presence of soft bedding in the sleep environment.  Some organizations recommend bedsharing as a means of supporting breastfeeding and cite data about the physiologic patterns and postures of mothers and babies when they bedshare.  Other recommendations focus on safe sleep and recommend breastfeeding as a strategy to reduce the risk of SIDS but recommend against bedsharing to avoid an unintended sleep-related death.

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Written by annkellams

March 14, 2019 at 10:27 am

Worldwide study on sudden infant death finds factors associated with poverty and racism are more important than bedsharing

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Last week, we published our novel study, “Sudden Infant Death and Social Justice: A Syndemics Approach,” showing that bedsharing – which has been the main focus of many interventions – is not the primary risk behind sudden infant death.

Instead, factors associated with poverty and racism have much more to do with Sudden Unexplained Infant Death (SUID), which includes suffocation, and its subset, SIDS (Sudden Infant Death Syndrome). Looking at populations around the world and the known risk factors for sudden infant death, we found that the vast majority of infants dying are from poor or marginalized populations, especially people who have experienced historical trauma. On the other hand, many wealthy and privileged populations have high rates to moderate rates of bedsharing,like Asian Americans and Swedes, yet have some of the lowest rates of SUID/SIDS in the world.

We used the medical anthropological theory of syndemics to help explain how social inequities that may be driven by historical forces and their legacies lead to the clustering of these risk factors, which ultimately results in higher death rates in poor and marginalized populations. It is important to view SUID/SIDS in the greater context of the growing field of social determinants of health.

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Written by Melissa Bartick, MD, MSc, FABM

August 27, 2018 at 4:10 pm

Posted in Uncategorized

The well-being of mothers and children is not a tradeable commodity

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Breastfeeding is the foundation of public health and economic development. All major medical organizations recommend 6 months of exclusive breastfeeding, followed by continued breastfeeding through the first one to two years of life and beyond.

Evidence continues to mount that disrupting optimal breastfeeding contributes to disease burden and premature death for women and children. Globally, optimal breastfeeding would prevent 823,000 child deaths each year. In the US, enabling optimal breastfeeding would prevent 721 child deaths and 2619 maternal deaths each year, as well as 600,000 ear infections, 2.6 million gastrointestinal illnesses, 5,000 cases of maternal breast cancer and more than 8,000 heart attacks.

Optimal infant feeding is also essential for economic development. Being breastfed is associated with a 3 to 4 point increase in IQ, leading to better school performance and workplace productivity. As stated by the World Bank’s Keith Hansen, “If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics.”

Breastfeeding is vital and essential to protect the world’s children, the most vulnerable who cannot speak for themselves.  Given the essential role of breastfeeding in global health and wellbeing, it is imperative that every nation supports policies and programs that enable women and children to breastfeed. It is therefore deeply troubling that the United States delegation to the World Health Assembly actively undermined efforts to enable optimal breastfeeding, as reported by the New York Times. Read the rest of this entry »

Written by bfmed

July 12, 2018 at 6:43 am

Separation of children and infants from parents – breastfeeding implications

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June 21, 2018 – The Academy of Breastfeeding Medicine, an international physician’s organization, condemns policies that result in the separation of parents from their children.

As the UN High Commissioner of Human Rights has established, “Children have the right to life, survival and development and to the highest attainable standard of health, of which breastfeeding must be considered an integral component.” Mothers similarly have the right to nurture their children: “Restriction of women’s autonomy in making decisions about their own lives leads to violation of women’s rights to health and, infringes women’s dignity and bodily integrity.”

“Separating children from their parents results in toxic stress that impacts breastfeeding and health for a lifetime,” said Timothy Tobolic MD, President of the Academy of Breastfeeding Medicine. “Furthermore, separating a mother from her breastfeeding child violates the human rights of both mother and child.”

Separation of the breastfeeding mother-baby pair further confers risk of acute illness for mother and child. Breastfeeding women who are separated from their infants and unable to drain their breasts will become engorged and are at risk for mastitis and breast abscesses. Unrelieved engorgement will precipitate involution and loss of milk supply.

Infants who are not breastfed face increased risks of ear infections, gastroenteritis and pneumonia. Separation of any infant from their mother also has untold emotional harms on those children. These risks are magnified if they are housed in facilities where proper preparation of formula or washing bottles and teats is not available.

Indeed, in emergency settings, such as refugee camps for migrant populations fleeing oppression, the first principal of the 2017 Operational Guidance for Infant and Young Child Feeding in Emergencies is the protection, promotion and support of breastfeeding. Separating a mother from her breastfed child violates this first principal.

ABM recommends reuniting infants and children with there parents without delay. When mother and child are reunited, the Academy of Breastfeeding Medicine and IYCFE guidelines recommend individual-level assessment by a qualified health or nutrition professional trained in breastfeeding and infant feeding issues. The mother-child pair will need sustained support to reestablish lactation, with access to an appropriate breast milk substitute until the mother’s milk supply is reestablished or until at least six months of age and beyond.

“We agree with President Trump’s executive order to stop the separation of infants and children from their parents.” said Dr. Tobolic. “Families belong together and breastfeeding must be supported for the health of the children.”

Written by bfmed

June 21, 2018 at 1:31 pm

Posted in Uncategorized

Breastfeeding Mitigates a Disaster

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Holocaust Memorial day, or as it is called in Israel and worldwide  as “Yom Hashoah”,  is combination of the most depressing sadness as we  of memorialize the 6,000,000 murdered victims  of Nazi Germany and their European collaborators, and  paradoxically, a celebration  of those individuals who somehow survived the horrors of mass murder and ethnic cleansing. The realization that 1.5 million infants and children were singled out  for elimination by the Nazi so as to prevent the chances  of a historical continuity of the European Jewish community is somehow counterbalanced by the miraculous stories of infants surviving, especially in the most unlikely circumstances and conditions.

This  past Yom Hashoah I had the opportunity to  view a documentary entitled “Geboren in KZ” (“Born in a Concentration Camp”, a film  by Eva Gruberova and Martina Gawaz for GDR Television )  which recounts the unbelievable story of 7 infants who were born in 1945 in  the Dachau, Germany  concentration camp. The fact that the mothers of these infants were able to conceal their pregnancies and reach term without being detected in of itself  defies comprehension, for as we know the policy of the Nazis was to send any women diagnosed as pregnant directly to the crematorium. Some of the women  even escaped  detection and “selection” for death  by the infamous Dr. Mengele in Auschwitz before being transferred to Dachau  No less  miraculous so was their ability to maintain a  minimal degree of nutrition to sustain their pregnancy till term or near term. Read the rest of this entry »

Written by aeidelmanmd

April 12, 2018 at 5:22 am

Posted in Uncategorized